Quality Improvement Resources

OBJECTIVES: To use PERISTAT data on indicators of maternal mortality and morbidity to explore maternal health outcomes in Europe, and to discuss the implications of variations in the data sources for these indicators.
STUDY DESIGN: The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Maternal mortality ratios are calculated, and data to describe maternal mortality by age, cause of death and mode of delivery are pooled for the countries that provided data.
RESULTS: Data presented show an increased risk of maternal death among older mothers and for caesarean sections compared with other modes of delivery, and the three most prevalent causes of maternal deaths reported were embolism, hypertensive diseases of pregnancy, and haemorrhage.
CONCLUSIONS: Variations in maternal mortality ratios reflect different data sources with varying levels of ascertainment in addition to differences in the number of maternal deaths. Further development is needed to construct comparable indicators of maternal morbidity.

n engl j med 358;18 www.nejm.org may 1, 2008 Background Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed. Methods We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention. Results The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention. Conclusions A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy. (ClinicalTrials.gov number, NCT00070720 [ClinicalTrials.gov] ; Current Controlled Trials number, ISRCTN82417627 [controlled-trials.com] .)

OBJECTIVE: The purpose of this study was to examine complications of labor induction compared to spontaneous labor in multiparas.
STUDY DESIGN: This was a retrospective cohort study of multiparous women with live, singleton pregnancies at term, who had no contraindications to labor or labor induction. Cesarean delivery was the primary outcome.
RESULTS: Of the study subjects, 7208 experienced spontaneous labor, 2190 underwent labor induction with oxytocin, and 239 underwent labor induction requiring cervical ripening agents. Oxytocin-induced multiparas were 37% more likely to require cesarean compared to those with spontaneous labor (OR, 1.37; 95% CI, 1.10-1.71) and nearly 3 times more likely to undergo cesarean when cervical ripening agents were used (OR, 2.82; 95% CI, 1.84-4.53). Women requiring cervical ripening were also 10 times more likely to spend more than 12 hours in labor than those with spontaneous labor.
CONCLUSION: Multiparas undergoing labor induction are at increased risk for obstetric complications compared to spontaneous labor.

Objectives: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. Methods: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. Results: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for babies born to women managed in the Magnolia Project compared to the same ratio for the United States. Conclusions: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the woman's health and subsequent reproductive health outcomes.

OBJECTIVE: To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage.
DESIGN: Retrospective questionnaire survey.
SETTING: Three administrative regions of France.
POPULATION: All women who were pregnant or had recently given birth during the year before the survey.
METHODS: A European survey (MOMS-B) defined severe haemorrhages as blood loss > or = 1500mL. A specific questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-five cases of severe haemorrhage were reviewed and classified into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and 'mixed' care were both considered substandard. The 165 cases were coded and then studied with uni- and multivariate analysis (logistic regression with SAS and SPSS software).
RESULTS: Of the 165 cases identified, 51% (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (<500 births per year) were the factors associated with substandard care.
CONCLUSION: Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the first time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be confirmed by others.

OBJECTIVE: To report the distribution and availability of the indicators describing the population of childbearing women in Europe and to assess the impact of the difference in the distribution of two of these indicators (age and multiple births) on some outcome indicators.
METHODS: The six PERISTAT indicators of population characteristics were computed using data from a survey of data providers in Europe. For maternal age and multiple births, the impact on health outcome was simulated for the extremes of the distribution using indirect standardised rates.
RESULTS: Data availability is good for basic demographic indicators (age, parity, multiple births), but less complete for indicators of social characteristics (education, smoking, country of birth). Further, common definitions are not used for the latter. Simulations of the impact of maternal age on health outcome found that variation in the maternal age distribution may cause trisomy 21 rates to differ by nearly 20% and maternal mortality ratios by nearly 50%.
CONCLUSION: Indicators of basic population characteristics are not collected routinely in every country. The crude distribution of these indicators is essential for international comparisons. Interpretation of comparative data would be improved by collection of health outcomes and service use by maternal characteristics.

OBJECTIVE: To assess the ability of the member states of the European Union to produce the indicators recommended by the PERISTAT project on perinatal health indicators and to provide an overview of fetal and infant health outcomes for these countries according to the information now available.
METHODS: We used data from the PERISTAT survey of data providers to compute PERISTAT indicators of fetal and infant health.
RESULTS: National data on fetal mortality are available for all countries, but vary in their definitions. To adjust for these differences in definition, PERISTAT recommends presenting rates by gestational age and birth weight. Not all countries can provide neonatal mortality data by gestational age, birth weight or plurality, as recommended by PERISTAT. Few countries in Europe can report infant mortality rates by birth weight and gestational age. The other recommended indicators are available to varying degrees.
CONCLUSIONS: This overview, which shows that Europe can produce a variety of indicators for monitoring the health of its new-borns, indicates that some key dimensions of perinatal health cannot now be measured with routine health statistics and reveals important disparities in health outcomes throughout Europe. For most indicators, the highest values are between 50 and 100% higher than the lowest values. The reasons for these variations and their importance for the surveillance of perinatal health are discussed.

The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.

OBJECTIVE: To estimate effective strategies for implementing clinical practice guidelines in obstetric care and to identify specific barriers to behavior change and facilitators in obstetrics.
DATA SOURCES: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and experts' suggestions.
METHODS OF STUDY SELECTION: Studies of clinical practice guidelines implementation strategies in obstetric care and reviews of such studies were selected. Randomized controlled trials, controlled before-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organization of Care criteria standards. TABULATION, INTEGRATION,
AND RESULTS: Studies were reviewed by two investigators to assess the quality and the efficacy of each strategy. Discordances between the two reviewers were resolved by consensus. In obstetrics, educational strategies with medical providers are generally ineffective; educational strategies with paramedical providers, opinion leaders, qualitative improvement, and academic detailing have mixed effects; audit and feedback, reminders, and multifaceted strategies are generally effective. These findings differ from data on the efficacy of clinical practice guidelines implementation strategies in other medical specialties. Specific barriers to behavior change in obstetrics and methods to overcome these barriers could explain these differences. The proportion of effective strategies is significantly higher among the interventions that include a prospective identification of barriers to change compared with standardized interventions.
CONCLUSION: Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the institute for Safe Medication Practices to a small list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring th effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

OBJECTIVE: To explore the effect of training on patient-actor perception of care during simulated obstetric emergencies.
METHOD: A subanalysis from a prospective randomised controlled trial in six UK hospitals and the Bristol Medical Simulation Centre, UK. Midwives and doctors working in participating hospitals were eligible for inclusion. 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were randomised to one of four obstetric emergency training interventions: 1-day course at local hospitals; 1-day course at simulation centre; 2-day course with teamwork training at local hospitals; and 2-day course with teamwork training at simulation centre. Local training used patient-actors and low-fidelity part-task trainers whereas simulation centre training used full-bodied computerised manikins and high-fidelity part-task trainers. Three weeks before and after the training, the participants managed three simulated obstetric emergencies. Patient-actors scored their care after each simulation using a patient-actor perception score (communication, safety, respect).
RESULTS: The following numbers of scores were awarded: 139 and 132 participant and 46 and 48 team scenarios, before and after training, respectively. There was a significant improvement in all scores in all scenarios after the training (p = 0.017 to >0.001). Perception of safety and communication during postpartum haemorrhage was significantly improved following training with patient-actors compared with training with manikins (safety p = 0.048, communication p = 0.035). Teamwork training offered no additional benefit to patient-actors' perception of their care.
CONCLUSIONS: All multiprofessional training improved patient-actor perception of care. Training using a patient-actor may be better at improving perception of safety and communication than training with a computerised manikin simulator

OBJECTIVES: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.
DESIGN: A prospective randomised controlled trial.
SETTING: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK.
POPULATION: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied.
METHODS: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre.
MAIN OUTCOME MEASURES: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention.
RESULTS: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965).
CONCLUSIONS: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

OBJECTIVES: To determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia and neonatal hypoxic-ischaemic encephalopathy (HIE).
DESIGN: A retrospective cohort observational study.
SETTING: A tertiary referral maternity unit in a teaching hospital.
POPULATION: Term, cephalic presenting, singleton infants born at Southmead Hospital between 1998 and 2003 were identified; those born by elective Caesarean sections were excluded.
METHOD: Five-minute Apgar scores were reviewed. Infants that developed HIE were prospectively identified throughout this period. The study compared the period 'pre-training' (1998-1999), with the period 'post-training' (2001-2003).
MAIN OUTCOME MEASURES: Five-minute Apgar scores and HIE.
RESULTS: Infants (19,460) were included. Infants born with 5-minute Apgar scores of <or=6 decreased from 86.6 to 44.6 per 10,000 births (P<0.001) and those with HIE decreased from 27.3 to 13.6 per 10,000 births (P=0.032) following the introduction of the training courses in 2000. Antepartum and intrapartum stillbirth at term rates remained unchanged, at about 15 and 4 per 10,000 births, respectively.
CONCLUSION: The introduction of obstetric emergencies training courses was associated with a significant reduction in low 5-minute Apgar scores and HIE. This improvement has been sustained as the training has continued. This is the first time an educational intervention has been shown to be associated with a clinically important, and sustained, improvement in perinatal outcome.

OBJECTIVE: To compare the effectiveness of training for eclampsia in local hospitals and a regional simulation center, with and without teamwork theory.
METHODS: This study is a randomized controlled trial of training in local hospitals and in a simulation center in the United Kingdom. Midwives and obstetricians working at participating hospitals were randomly assigned to 24 teams. Teams were randomly allocated to training in local hospitals or at a simulation center, and to teamwork theory or not. Performance was evaluated before and after training with a standardized eclampsia scenario captured on video. Outcome measures were completion of tasks, time to completion of tasks, administration of magnesium sulfate, and quality of teamwork.
RESULTS: Training was associated with an increase in completion of basic tasks; 87% before training and 100% afterward. Basic tasks were completed more quickly; 55 seconds compared with 27 seconds, P=.012. The magnesium sulfate loading dose was administered by 61% of teams before training and by 92% afterward (P=.040). There was a shorter median time to administration (116 seconds less; P=.011). Training at the simulation center was not associated with additional improvement. Teamwork generally improved (median global score rose from 2.5 to 4.0; P<.001) but there was no additional benefit from teamwork training.
CONCLUSION: Training resulted in enhanced performance with higher rates of completion for basic tasks, shorter times to administration of magnesium sulfate, and improved teamwork. There was no additional benefit from training in a simulation center, and none from teamwork theory.
CLINICAL TRIAL REGISTRATION: ISRCTN, http://isrctn.org, ISRCTN67906788, reference number 0270030.

BACKGROUND: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review.
PURPOSE: To synthesize the evidence for using publicly reported performance data to improve quality.
DATA SOURCES: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999-2006) and independent review of articles (1986-1999) identified in a previous systematic review. Only sources published in English were included.
STUDY SELECTION: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences.
DATA EXTRACTION: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted.
DATA SYNTHESIS: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider-level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant.
LIMITATIONS: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included.
CONCLUSION: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.

A great essay on the history of the APGAR score and how obstetrics has changed with its focus on baby outcomes over the last generation. Atul Gawande's writing style works well for both lay and professional audiences.

This is an essay on the use of checklists in medical quality improvement and profiles Peter Pronovost's translational research in their use in ICUs. Atul Gawande's writing style works wonderfully for both lay and professional audiences. This is a great tool to use when introducing a checklist into a new medical service.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline.
METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals.
RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use.
CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

The need to monitor progress in reducing maternal mortality has a long history, which can be traced back to the 1700s in some parts of the Western world. Today, however, this need is felt most acutely in developing countries, where the priority is to stimulate, evaluate and sustain action to prevent these essentially avoidable deaths. Over the last two decades, considerable efforts have been made to understand and overcome the measurement challenges of maternal mortality in the context of weak information systems, and new and enhanced methods and tools have emerged.

This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.

Objectives: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. Data sources: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. Review methods: Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. Results: In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. Conclusions: There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

This article outlines an approach to improve patient safety in obstetrics and gynecology, with the goal to reduce errors in labor and delivery. Every institution should create guidelines and provide education and training to address potential safety issues such as fetal heart rate pattern interpretation, induction and stimulation of labor, vaginal birth after cesarean, magnesium sulfate, shoulder dystocia, hemorrhage, forceps/vacuum, and thromboembolic disease. This article discusses the patient safety objectives published by the American College of Obstetricians and Gynecologists Committee on Quality Improvement and Patient Safety; the National Patient Safety Goals, which are regularly established by the Joint Committee on Accreditation of Healthcare Organizations; and patient safety indicators developed by the Agency for Healthcare Research and Quality.

This article outlines an approach to improve patient safety in obstetrics and gynecology, with the goal to reduce errors in labor and delivery. Every institution should create guidelines and provide education and training to address potential safety issues such as fetal heart rate pattern interpretation, induction and stimulation of labor, vaginal birth after cesarean, magnesium sulfate, shoulder dystocia, hemorrhage, forceps/vacuum, and thromboembolic disease. This article discusses the patient safety objectives published by the American College of Obstetricians and Gynecologists Committee on Quality Improvement and Patient Safety; the National Patient Safety Goals, which are regularly established by the Joint Committee on Accreditation of Healthcare Organizations; and patient safety indicators developed by the Agency for Healthcare Research and Quality.

Oxytocin is 1 of the most commonly used drugs in labor and has been associated with adverse maternal and fetal outcomes. In an attempt to improve patient safety, we constructed a standardized protocol for labor induction with oxytocin. We reviewed the numerous publications regarding oxytocin use for either induction or augmentation of labor in order to determine if there was a protocol available that would maximize success of delivery and minimize the adverse maternal and fetal effects of the drug. Using the literature review and the specific pharmacokinetics of oxytocin, we developed a standardized approach for the dilution and administration of oxytocin in order to improve patient safety, develop uniformity of the drug use, maximize its benefits, and minimize its side effects. We suggest that a standardized approach to oxytocin use be adopted that uses an oxytocin dilution of 10 mU/mL, initial dose of 2 mU/min (12 mL/hr), incremental increase of 2 mU (12 mL) every 45 minutes until adequate labor with the maximum dose being 16 mU/min (96 mL/hr). Key words: augmentation, induction, oxytocin, Pitocin

Issues related to the development and implementation of clinical pathways require thoughtful planning, collaborative teamwork, and an understanding of the evolutionary nature of this work. Creating an understanding of the purpose behind the development of these guidelines often is only the first issue to be considered. Other common issues include physician involvement, documentation, pathway development, variance data analysis and feedback, and integration with outcomes management activities. Successfully addressing these issues is an ongoing component of a clinical pathway program.

Background: Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective. Objectives: To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy: We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004. Selection criteria: Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis: Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality. Main results: Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies. Authors' conclusions: Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for maternal newborn care in a perinatal regional referral institution. Core issues in the design of this system are addressed to promote outcomes management and ongoing performance improvement. A discussion of the implementation follows, illustrating the lessons learned, changes made, and associated evaluation. This clinical pathway system has improved communication and collaboration among all disciplines, enhanced the discharge coordination process, and established protocols available to all members of the health care team.

Australia is one of the safest countries in the world to birth. Because maternal deaths are rare, often the focus during pregnancy is on the well-being of the fetus. The relative safety of birth has fostered a shift in the focus of maternal health, from survival, to the model of care or the birth experience. Yet women still die in Australia as a result of child bearing and many of these deaths are associated with avoidable factors. The purpose of this paper is to outline the maternal death monitoring and review process in Australia and to present to clinicians the salient features of the most recently published Australian maternal death report. The notion of preventability and the potential for practice to have an effect on reducing maternal mortality are also discussed.

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.

Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.

As 200 million women become pregnant every year, at least 30 million will develop life-threatening complications requiring emergency treatment at any level of society where they live. But it is a basic human right that pregnancy be made safe for all women as complications are mostly unpredictable. This requires reproductive health programmes which are responsive to women's and their families' needs and expectations on the one hand and enhancement of community participation, high quality obstetric services, and both provider collaboration and satisfaction on the other. Monitoring and evaluation of these facets need to be an integral part of any safe motherhood programme, not only to assess progress, but also to use this information for subsequent planning and implementation cycles of national programmes. Lessons learned from ten years' implementation of Safe Motherhood programmes indicate that process and outcome indicators are more feasible for short-term evaluation purposes than impact indicators, such as maternal mortality reduction. The former are described in this paper with relevant country examples. This is the third, and last, article in a series on quality of care in reproductive health programmes. The first (Kwast 1998a) contains an overview of concepts, assessments, barriers and improvements of quality of care. The second (Kwast 1998b) addresses education issues for quality improvement. PIP: This article outlines the quality of care in reproductive health programs by monitoring and evaluating quality improvements. Values of medical audit, verbal autopsies, and selected process and outcome indicators pertaining to safe motherhood component of reproductive health programs are illustrated to measure various aspects of quality of care. The International Federation of Gynecology and Obstetrics (FIGO) recommends the method of maternal death audits for the purpose of teaching and improving services at all level in the maternity care pyramid. In the selection process and outcome indicators, this requires collaboration between various international agencies and universities. Each projects and programs should require appropriate indicators for monitoring and evaluation; hence, the choice will depend on program interventions. The availability of humane and functioning obstetric services, which are geographically accessible and financially affordable, encourages families to seek care. Moreover, discussions in improving quality must consider client satisfaction and provider fulfillment.

The main purpose of this article is to point out common pitfalls that can confuse comparative analyses of indicators of perinatal health and to discuss ways to overcome or minimize these difficulties. The challenge is to distinguish 'real' variations in the value of an indicator from variations due to differences in registration practices and definitions and from random variation. The first section presents the major properties that are desirable in indicators of perinatal health status and perinatal health care in Europe to be used for comparative purposes. The second section provides specific examples of the types of methodological difficulties encountered in European cross-country comparisons due to variations in the definition, measurement and construction of indicators. The conclusion discusses the PERISTAT project's responses to these difficulties and how these methodological constraints impact on the selection of an appropriate indicator set for Europe today.

Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly “changed the conversation” to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010.

OBJECTIVE: To analyze the influence of level of perinatal care of the maternity unit on the rate of cesarean delivery during labor among women with low-risk pregnancies.
METHODS: Using data from the PREMODA (PREsentation et MODe d'Accouchement: presentation and mode of delivery) study of 138 French maternity units, the delivery method in 3,654 low-risk nulliparas (live singleton fetus in cephalic presentation at term [37-41 weeks of gestation], born weighing 2,500-4,500 g, no uterine scar, no cesarean before labor, and no induction of labor for maternal or fetal disorders) was analyzed. Independent variables included maternal and fetal characteristics and the level of perinatal care of the maternity unit (level 1, 2a, 2b, and 3; where levels 2b and 3 routinely manage high-risk pregnancies). Univariable and multivariable analysis with a multilevel logistic model explored the factors associated with cesarean delivery during labor.
RESULTS: Overall, the rate of cesarean during labor was 11.7%. The rate was significantly higher in level 2b (odds ratio 1.5, 95% confidence interval 1.1-2.1) and 3 (odds ratio 1.3, 95% confidence interval 1.0-1.9) maternity units than in level 1 facilities. The size and status of the facilities did not significantly affect these rates. Risk factors for cesarean were older maternal age, non-French origin, gestational age of 41 weeks, male sex, and high birth weight.
CONCLUSION: Maternity units that frequently manage high-risk pregnancies (levels 2b and 3) have higher rates of cesareans during labor for their population of nulliparas at low risk than do facilities that deal mainly with low-risk pregnancies (level 1).
LEVEL OF EVIDENCE: II-2.

Every year, some eight million women around the world suffer pregnancy-related complications; over half a million of these women die. Although most of these deaths could be averted at little or no extra cost, even where resources are limited, if we are to take action and develop and implement changes to maternity services to save the lives of mothers and newborns, we need the right kind of information. This more in-depth information might not be available through national statistics on maternal mortality rates or death certificate data; what is required is a detailed understanding of the clinical, social, cultural and other underlying factors that result in a mother's death. The World Health Organization's programme and philosophy for such maternal death or disability reviews is called Beyond the numbers. It outlines the five key methodologies for reviewing maternal deaths or disabilities that are now being introduced in a number of countries around the world.

OBJECTIVE: To identify processes affecting agency for safety among perinatal nurses, physicians, and certified nurse-midwives.
DESIGN: Grounded theory, as informed by Strauss and Schatzman.
SETTING: Two academic perinatal units in the western United States.
PARTICIPANTS: Purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives.
FINDINGS: Agency for safety (the willingness to take a stand on an issue of concern) fluctuated for all types of providers depending on situational context and was strongly influenced by interpersonal relationships. While physicians and certified nurse-midwives believed that they valued nurses' contributions to care, their units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Nurses' confidence was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor interpersonal relationships, resulting in a process of redefining the situation as a problem of self.
CONCLUSIONS: Women and babies should not be dependent on the interpersonal relationships of providers for their safety. Clinicians should be aware of the complex social pressures that can affect clinical decision making. Continued research is needed to fully articulate facilitators and barriers to perinatal safety.

This paper uses the results of the PERISTAT feasibility study to assess the extent to which the participating countries of Europe were able to provide data to construct the core and recommended indicators of perinatal health defined in the project. After describing the approaches used for data collection in participating countries, this paper describes the extent to which they were able to provide the data requested to construct the indicators. It documents data sources within each country and their characteristics. The paper then discusses influences on the agenda, particularly the extent to which data collection occurs as a by-product of other processes such as civil registration and the administration of health care and how these processes can both enable and impede data collection. It closes by suggesting how data collection in Europe can be improved in order to widen the scope of the agenda for compiling perinatal indicators.

OBJECTIVE: The purpose of this study was to identify an appropriate population and a balanced set of maternal and neonatal measures to drive a hospital network obstetric quality improvement program.
STUDY DESIGN: Sutter Health, a large Northern California health care system with>40,000 births annually, served as the site for this project. We chose to focus on the standardized nulliparous patients: term, singleton, and vertex. A multidisciplinary task force evaluated and selected perinatal outcome and process measures. Data from every hospital were collected prospectively electronically and analyzed centrally.
RESULTS: Outcome measures that were selected included term, singleton, and vertex rates of 3rd/4th-degree laceration, cesarean birth, 5-minute Apgar score of <7, and patient satisfaction. The process measures included episiotomy, induction (37-41 weeks), and admittance with cervical dilation of > or =3 cm. Data collection completeness improved each quarter; by the end of 2002, the data collection completeness rate had reached 99.7%. Every measure demonstrated a large variation among our hospitals, which indicates opportunities for improvement.
CONCLUSION: This balanced set of measures for term, singleton, and vertex patients has been straightforward to collect over a large and diverse hospital system and has engaged all participants successfully.

Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or "health courts," attract considerable policy interest during malpractice "crises," including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations.

OBJECTIVE: The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions.
CONTEXT: Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety.
MODEL FOR IMPROVEMENT: Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates.
CONCLUSIONS: We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections--both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign--culture, it targets 3 important groups--senior leaders, team leaders, and front line staff, and facilitates change management-engage, educate, execute, and evaluate for planned interventions.

This study reviewed maternal morbidity following trial of labor (TOL) after cesarean section, compared with elective repeat cesarean delivery (ERCS). Articles were pooled to compare women planning vaginal birth after cesarean (VBAC) with those undergoing ERCS with regard to maternal morbidity (MM), uterine rupture/dehiscence (UR/D), blood transfusion (BT), and hysterectomy. The former group was subdivided into successful VBAC (S-VBAC) and failed TOL (F-TOL). VBAC was successful in 17,905 of 24,349 patients (73%). MM, BT, and hysterectomy were similar in women planning VBAC or ERCS, whereas UR/D was different (1.3%; 0,4%). MM, UR/D, BT and hysterectomy were more common after F-TOL (17%, 4.4%, 3%; 0.5%) than after S-VBAC (3.1%, 0.2%, 1.1%; 0.1%) or ERCS (4.3%, 0.4%, 1%; 0.3%). Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.

Failure to rescue is an indicator that has been used to measure quality of care for surgical patients by evaluating the number of patients who die after developing postoperative complications. There are 2 key components of failure to rescue: (a) careful surveillance and timely identification of complications and (b) taking action by quickly initiating appropriate interventions and activating a team response. This concept has not been explored as a potential method to evaluate quality of intrapartum care. In obstetrics, complications leading to death are relatively rare because mothers and infants are generally healthy. Thus, there are not large numbers of maternal or infant deaths in individual hospitals or healthcare systems that allow the types of statistical analyses that have been previously used to measure failure to rescue rates. With modifications in the measurement process for failure to rescue in this population, there are direct implications for perinatal patient safety and lessons to be learned. A new use of the failure to rescue concept in a population not previously considered is proposed.

Evidence-based medicine is an important tool for improving the quality of maternity care. However, getting providers to change their practices may not be an easy or rapid process, and other factors, in addition to knowledge of the literature, may be important. This study documents the current state of obstetric practices at three maternity hospitals in Istanbul, Turkey, and identifies attitudes, social pressures, and perceptions that, according to the theory of planned behavior, may pose challenges for adoption of evidence-based practices. Data were collected through interviews with administrators, examination of hospital statistics, provider and client interviews, and structured observations of maternity care. Practices that did not follow current guidelines included routine episiotomy, not allowing companionship during labor, use of procedures to speed up labor without indications, routine enema, restriction of mobility, restriction of oral fluids, supine position for delivery, and non-use of active management of the third stage of labor. The findings indicate that providers had negative attitudes about some recommended practices, while they had positive attitudes towards some ineffective and/or harmful practices. We identified social pressure to comply with practices recommended by supervisors and peers, as well as the belief that limited resources affect maternity care providers, opportunities to perform evidence-based procedures. An underlying problem was the failure to involve women in decision-making regarding their own maternity care. In addition to informing providers about the evidence, it seems necessary to develop standard protocols, improve physical conditions, and implement behavior interventions that take into account provider attitudes, social pressures, and beliefs.

Most health care professionals who are involved in efforts to improve patient safety are aware of James Reason’s “Swiss cheese” model of how accidents occur. Some elements and pressures of current obstetric practice may weaken defenses and safeguards against perinatal injury. Several components of obstetric care in labor and delivery units can be used as targets for tightening the “holes” in the Swiss cheese model. These include improving communications, preparing for rare critical events through simulation training, developing protocols for administration of important medications used in labor and delivery (oxytocin, misoprostol, and magnesium sulfate), increasing the in-house presence of obstetricians, developing an effective departmental infrastructure that includes effective peer review, providing risk management education about high-risk clinical areas that have the potential to result in catastrophic injury, and staffing the unit for all contingencies during all hours, day and night. Acceptance by the obstetric medical staff is critical to the implementation of these patient safety elements. (Obstet Gynecol 2007;110:1146–50)

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.

OBJECTIVES: To describe variation across Europe in PERISTAT indicators of health care in the perinatal period, and to assess the comparability of these indicators.
STUDY DESIGN: The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Comparative analysis includes descriptions of births following management of sub-fertility, timing of first antenatal visit, onset of labour, mode of delivery, place of birth, preterm births in units without NICU, and breast-feeding uptake.
RESULTS: There is broad variation in the availability to provide data on perinatal indicators, and in perinatal health care across the European Union.
CONCLUSIONS: This paper describes the challenge of identifying indicators that are meaningful and robust for the full distribution of health care systems represented in the European Union. Further work is needed to ensure that the implementation of each indicator is comparable across member states.

BACKGROUND: The PERISTAT project aimed to develop an indicator set for monitoring and describing perinatal health in Europe. The challenge was to define indicators that cover common concerns and have the same meaning within the different European health care systems.
METHODS: PERISTAT included i) a review of existing recommendations on perinatal health indicators, ii) a DELPHI consensus process with a scientific advisory committee composed of a clinician and an epidemiologist or statistician from each European member state as well as with a panel of midwives, and iii) a study of the availability of national statistics to construct recommended indicators. This article describes the first two components.
RESULTS: The review identified 10 international and 13 national recommended indicator sets. It also included indicators routinely compiled by WHO, EUROSTAT and OECD. Because of the methodological limits to using existing indicators for European comparisons, a high priority was placed on improving indicators already collected. Using the DELPHI method based on the results of the review, the scientific committee achieved a consensus on ten core and 23 recommended indicators, including 12 requiring further development.
CONCLUSIONS: The PERISTAT project was successful in identifying a set of indicators, which drew on and consolidated previous work. Consensus was not achieved on precise indicators in areas where uncertainty about appropriate indicators was high, although areas were targeted for future development. Finally, the feasibility study, which is in progress, is an essential part of the project, since it will enable member states to evaluate their capacity to produce these indicators.

The PERISTAT project was charged with developing an indicator set for monitoring and describing perinatal health in Europe as part of the European Commission's Health Monitoring Programme, run by the Directorate General for Health and Consumer Protection (DG-SANCO), which is working towards the establishment of a comprehensive health monitoring system at the community level. To develop its recommendations, the PERISTAT project carried out an extensive review of existing perinatal health indicators and then implemented a DELPHI consensus process with its scientific advisory committee, a panel composed of clinicians, epidemiologists and statisticians, as well as with a panel of midwives. Consensus was achieved on 10 core and 23 recommended indicators using methods that drew on and consolidated previous work in this field. Twelve of these indicators were targeted for further development and the other 21 for immediate implementation. A feasibility study, reported in the rest of this issue, was put into place to assess these recommendations.

The Seventh Report of the United Kingdom Confidential Enquires into Maternal Deaths (2003-2005). Slide set provided by Dr Gwyneth Lewis, CEMACH Clinical Director, Maternal Death Enquiry.

An overview of the role of the California Maternal Quality Care Collaborative (CMQCC) to reduce the rising rates of maternal mortality and the associated increase in maternal morbidity in the state of California. The innovative connection of a quality improvement collaborative with the California Pregnancy-Related and Pregnancy-Associated Mortality Review committee facilitates the more rapid diffusion of findings into action.

A reasonable trigger tool for nursing charting on L&D. From: Appendix to Saving Mother's Lives (2007); also published in: International Journal of Obstetric Anesthesia (2006) 15, S1-S43 Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists? Association, Glasgow 11-12 May, 2006. “Early-warning scoring in obstetrics”. P Harrison, C Hawe, F McIlveney. Department of Anaesthesia, Stirling Royal Infirmary, Stirling, UK.